35 Before the nationwide implementation of IAPT it was argued that a strong lead from the Department of Health in the initial phases of the roll-out would be an important means to ensure the quality of the therapy provided [100]. This argument was supported by the experiences made by the demonstration sites in Newham and Doncaster which focused either on high- or low-intensity therapy, and therefore did not implement the stepped model of care recommended by the NICE guidelines. It thus became clear that central governance and clear national standards were necessary for the NICE guidelines to be followed consistently in the IAPT services in the full roll-out [106].
As a result, there is a high degree of national governance in IAPT, with the main aspects of the services predetermined by central authorities. The organization and running of the services, as well as the training programmes for the new therapists was specified by a number of expert groups appointed by the Department of Health [69]. The work of the expert groups resulted in a national implementation plan to support the local delivery of IAPT [75], and several support documents that further specify the organization of the services, leaving little room for local variations in key aspects of the services [77, 124, 132].
IAPT is administered according to the NICE guidelines, and the national specifications are meant to support local development of NICE compliant services. This entails that new guidelines for the services will be issued when the NICE guidelines are revised and changed [75]. Although many aspects of the services are determined centrally, the exact
configurations are meant to be agreed locally [75]. It has also been stated that the need for central control will diminish when the IAPT services are fully established according to the national guidelines, making a more decentralized governance of IAPT possible [104].
In addition to the national documents specifying the nature of the IAPT services, the commissioning of IAPT is controlled by a hierarchy of expert and programme groups. On the
36 top resides the National Programme Board which ensures that IAPT services operate in alignment with the instructions from the Directorate of Health and the Government. At the next level there is an expert reference group and a programme management group, each with several underlying groups with clearly specified fields of responsibility, such as education and training [128]. The performance of the IAPT services is monitored and reported on four different levels, ranging from national to local monitoring. The outcome measurements obtained in the individual services inform them on their progress and is reported to the PCTs who monitor the local performance of the services within their area of responsibility. The PCTs report to the SHAs who monitor the status of the regional
commitments and report to the central programme board that monitors the status of the national commitments, ensuring that they are achieved [128].
In the governance of the PPHC services, there is a high degree of local autonomy. The guidance for development of the services issued by the Norwegian Directorate of Health comprises such an extensive variety of interventions that it functions like a framework for the services rather than clear national standards [72].
Regarding the monitoring and control of PPHC, it is obligatory for the municipalities who are a part of the initiative to complete a form for status report once every year while they receive funding for the service. They report on whether the municipality has succeeded in hiring a psychologist, which organizational model the psychologist works within, the visibility of the service, the individual-, family-, group-, and population-based interventions used by the psychologist, the financing of the services and their future goals [127]. The status reports are revised by the Directorate of Health who performs the central monitoring [127]. The municipalities are also required to account for internal and external supervision
37 precautions, such as internal audit and reports to the Office of the Auditor General of
Norway [72].
While the IAPT services are subject to central governing and control, the PPHC services have a greater degree of local autonomy. This difference between IAPT and PPHC is also evident in the respective healthcare systems in general. The emphasis on central
governance in IAPT and local control in PPHC can be traced back to the differences in the respective governments' politics. In England, the modernization process of the NHS the past 15 years has led to an increasing focus on national standards, central support of local services and measurement of progress in all health services [67, 101]. In contrast, a central aspect of the Norwegian healthcare system is an emphasis on local governance in the municipalities. In Norway, the municipalities have the overall responsibility for the
healthcare services, and it is the government's intent that each municipality choose how to organize their services on the background of local circumstances and needs within the frames set out by laws and regulations [60].
A likely result of these differences in the healthcare systems in general, and in IAPT and PPHC services in particular, is that while IAPT services are quite similar in their
organization and functioning, there exists a greater variety between PPHC services. This could also entail a varying degree of quality between the PPHC services, where quality
depends on local initiative and the competences of the individual psychologist working in the service. Thus, while PPHC has the advantage of incorporating local knowledge and
circumstances in the locally developed services, IAPT has the advantage of central
commissioned quality control, providing them with a broader knowledge and evidence-base to build their services on.
38 14. Evaluation of the services and the initiatives as a whole
The achievements of IAPT are evaluated according to three headline outcome indicators set out by the Secretary of State. First, a minimum of 20 PCTs should implement IAPT in
2008/09, with increasing coverage over the subsequent two years. Second, 3,600 new therapists should be trained by 2010/11, and third, 900,000 people should receive
treatment, with half of those completing treatment moving to recovery and 25,000 fewer on sick pay and benefits by 2010/11 [75]. The outcome indicators are clearly formulated and operationalized in a manner that makes it easy to evaluate the progress, and report this to the health care commissioners [132].
The foundation of the evaluation is routine data collection of patient status and progress, which is a key characteristic of the IAPT services [132]. Following the impressive data completeness from the demonstration sites which used a session-by-session
monitoring system, a part of the recommended data set is mandatory for all IAPT sites receiving central funding [132]. The data set includes scores on measurements for
depression and anxiety, employment status and disorder specific measures if appropriate [132]. This session-by-session monitoring system is fundamental in delivering a stepped model of care, where knowledge of the patient's progress determines the adjustment of further treatment [77]. It also helps the service providers improve their services, thereby improving people's benefits from treatment in IAPT. Another positive effect of the outcome monitoring is the high degree of data completeness, which is essential in evaluating IAPT and reporting the effects of the project to the government. Several evaluations of the progress of IAPT have been published based principally on these data [98, 106, 128].
Evaluation of the IAPT services is also incremental for the continuation of the project and continued government support. From the outset it was clear that a large scale
39 implementation and funding of IAPT depended on the outcomes in the demonstration sites [69]. As well as determining the future of the IAPT project, evaluations of individual services are used to improve those services who do not meet the expected patient throughput and recovery [132].
The main goal of PPHC is to increase the number of psychologists working in the Norwegian municipalities, which is easily determined. However, the goal was not quantified from the outset of PPHC, making evaluation of goal attainment difficult. In 2010, the
Department of Health estimated, based on the experiences from the first two years of the initiative, that 110 new psychologists would be recruited by 2011 [133].
Another central goal is the implementation and testing of different organizational models for the services, which is another goal without clear evaluation criteria. There are also a number of criteria for goal attainment of the individual services, which the
municipalities are supposed to report on each year. The report consists of a written reply to 10 questions regarding the organizational and structural aspects of the services, such as the psychologist's job description, whether the psychologist are involved in multidisciplinary work and supervision of other health care workers and how the psychologist's position is incorporated into the municipal organization [127]. The municipalities report on these criteria to the Directorate of Health. If the municipality reports incorrect information or the subsidy is not used according to the prerequisites, the funding can be terminated [70].
Based on the diffuse criteria of the PPHC one can wonder whether the presence of a few newly recruited psychologists who work within each of the four different models is enough to call the project a success. Although the goals of the PPHC are not clearly
formulated and there is a lack of evaluation criteria, the effects of PPHC are currently being evaluated by two Norwegian research organizations, SINTEF and the Work Research
40 Institute, on behalf of the Directorate of Health. They are conducting interviews with the psychologists working in the municipalities and their collaboration partners, and have sent out a survey to all psychologists employed in municipal services. They are investigating the effect of the different organizational models on the work of psychologists in the
municipalities, whether the recruitment of psychologists has increased and how the different models contributes to coordination with other services and professionals [134].
This research will be concluded in December 2012 [135].
Both in IAPT and PPHC it has been clear since the beginning that the continuation of the programmes, with additional funding from the government, depends on the outcomes of the first three-year period [133]. While the main focus on the evaluation of IAPT is based on patient outcome and the effectiveness of the services, the evaluation of PPHC focuses on organizational and structural aspects of the services. There is currently no research on how PPHC affects the inhabitants of the municipality and their psychological functioning, and we do not know of any plans to conduct such research. Since there is no system in place to collect data on the effectiveness of the services, or the health status of the target group, it is not evident how such research could be accomplished.
While the importance of evaluation is emphasised in IAPT, in PPHC it was not clear from the beginning whether, let alone how, evaluation of the services would be conducted.
In the regulations of PPHC it is stated that there would be an on-going consideration by the Directorate of Health and the Ministry of Health and Care Services as to whether PPHC should be evaluated [70]. Thus, no systematic evaluation was planned from the outset of PPHC, in contrast to the emphasis placed upon evaluation in IAPT.